Variants of development and management of patients with persistent atrial fibrillation

The article discusses controversial aspects of modern management of patients with persistent atrial fibrillation (AF). The appearance of a persistent form of AF is mainly a consequence of the processes of fibrosis and electrical restructuring (remodeling) of the atrial tissue. However, the question of the causes and mechanisms of the formation of fibrosis of the atrial tissue is quite debatable. The suggestions of experts regarding the division of persistent AF depending on the features of the arrhythmological anamnesis are presented: the appearance of persistent episodes of AF as a stage of disease progression in patients who previously had a paroxysmal form of arrhythmia, or «persistent AF from the beginning». From the standpoint of predicting the course of the disease and differentiating the management of patients, there are also grounds for distinguishing «early persistent AF» in cases where the duration of the episode is more than 7 days and less than 3 months, as well as «late persistent AF» lasting from 3 to 12 months. From the point of view of evidence-based medicine, the paradigm of managing patients with persistent AF is shifting towards the fastest and most aggressive fight for sinus rhythm. Changes in favor of the rhythm control strategy have largely occurred due to the rapid development of catheter treatment technologies. Its effectiveness is generally lower than in paroxysmal AF, which is due to more pronounced structural remodeling of the atria, as well as electrophysiological changes in the myocardium against the background of a prolonged episode of arrhythmia. At the same time, research into new techniques using modification of the arrhythmia substrate is ongoing.